Introduction

Distal radius fractures are a common complication associated with falls in the elderly. The incidence is predicted to rise in the coming years. Currently, no evidence-based rehabilitation interventions have yet been established, which is astonishing since the incidence of distal radius fractures is expected to increase in the coming years. When a closed reduction is opted for, this is usually followed by cast immobilization followed by physiotherapy referral or self-exercise. Previous research on distal radius fracture rehabilitation showed mixed results, prompting the need for long-term comparative studies. Reid et al. in 2020 found that adding mobilization-with-movement to exercise and advice sped up recovery for supination mobility. This contradicted findings from older studies by Wakefield and Watt published in 2000, which questioned the need for physiotherapy treatment. Therefore, the current RCT wanted to understand the best method of distal radius fracture rehabilitation after casting by comparing whether supervised physiotherapy consisting of exercises and mobilization techniques was superior to a home exercise program consisting of self-exercises.

Methods

This study aimed to determine whether supervised physiotherapy is a more effective option for distal radius fracture rehabilitation than a home exercise program for functional improvement and pain relief in patients older than 60 years.

Design and Setting: The research was a single-blinded, randomized controlled trial conducted at the Clinical Hospital San Borja Arriaran in Santiago, Chile. Ethical approval was granted, and the trial was registered prospectively.

Participants: The study included 74 patients over 60 years old with A3 extra-articular multifragmentary distal radius fracture. Exclusion criteria included any surgical intervention for distal radius fracture reduction/fixation, complications post-cast removal (such as CRPS), or cognitive impairments.

Interventions: Participants were randomly assigned to two groups:

• Supervised Physiotherapy Group: These participants received 6 weeks of supervised sessions involving active wrist and hand exercises, joint mobilization, and motor skill training twice a week.
• Home Exercise Program Group: These people were given instructions for a home-based exercise regimen focusing on pain reduction, passive exercises, and dynamic muscle exercises over 6 weeks.

The supervised physiotherapy group participated in a structured program over 6 weeks, attending twelve sessions scheduled twice a week. Each session comprised several components aimed at improving wrist and hand function, reducing pain, and enhancing overall mobility.

1. The first part of each session involved active wrist and hand exercises performed in a whirlpool set at 34°C for 15 minutes. The warm water helped increase joint mobility and reduce stiffness, preparing the joints and muscles for subsequent interventions.
2. Following the whirlpool exercises, patients underwent joint mobilization techniques. During the initial two weeks, the Maitland technique (Grade II or III) was applied. This technique involved one cycle per second for one minute and aimed to improve joint mobility and alleviate pain. For the remaining four weeks, the Kaltenborn method, involving sustained Grade I glide mobilizations, was used. These mobilizations were performed in anteroposterior and posteroanterior directions with the distal radius stabilized in a neutral position, maintaining joint integrity and enhancing mobility.
3. Additionally, each session included motor skill training exercises tailored to improve hand function and coordination. These exercises consisted of controlled grip strength exercises with visual pressure biofeedback, reverse dart-throwing exercises focused on the precision of the first interosseous space, and scapular retraction exercises. To prevent pain and muscle fatigue, patients performed these exercises with short-duration, low-intensity repetitions, completing each exercise 8-10 times, maintaining each task for five seconds, and resting for 10-30 seconds between tasks.

The home exercise program group followed a 6-week regimen, performing exercises daily at home. Initially, each patient had an appointment with a physiotherapist who provided detailed instructions for the exercises. The program was divided into three phases, each spanning approximately two weeks.

1. During the first two weeks, the exercises prioritized pain reduction and edema control. Patients engaged in gentle activities such as finger stretching and spreading exercises, grip strength exercises, forearm stretching, and bending and stretching the elbow. They also performed abduction/adduction and external/internal rotation of the arm to maintain shoulder mobility.
2. In the third and fourth weeks, the focus shifted to early active motions without resistance, continuing with the previously introduced finger and grip strength exercises, and incorporating forearm, elbow, and arm movements to further enhance joint mobility and strength.
3. The final two weeks introduced dynamic muscle exercises with light resistance to build strength and improve the functional use of the wrist and hand. Patients continued to perform the earlier exercises while gradually increasing the intensity.

Each home exercise session lasted one hour, and patients were expected to perform the exercises daily. The physiotherapists monitored adherence through weekly phone calls, checking on the frequency and dose of the exercises

Outcome Measures: The primary outcome was wrist and hand function assessed using the Patient-Rated Wrist Evaluation (PRWE). A score of 100 represents the worst functional score, whereas 0 represents no disability. The minimal clinically important difference (MCID) is 15 points. Secondary outcomes included pain intensity (VAS), grip strength, and wrist flexion-extension active range of motion.

Results

The supervised physiotherapy group showed significantly greater improvements in wrist function at 6 weeks and 1 year compared to the home exercise group. At 2 years, the difference decreased, showing only a minor improvement in favor of supervised physiotherapy.

Secondary Outcomes:

• Pain Intensity: Both groups reported pain reduction, but the supervised physiotherapy group had a more substantial decrease at 6 weeks and 1 year. By 2 years, the difference was minimal.
• ROM: The supervised physiotherapy group had greater improvements in wrist flexion and extension at 6 weeks and 1 year. This effect diminished over 2 years.
• Grip Strength: The supervised physiotherapy group maintained significant gains in grip strength throughout the 2-year follow-up.

Questions and thoughts

This trial indicates the importance of supervised distal radius fracture rehabilitation for improving wrist function in the short (6 weeks) and medium-term (1 year). When looking at the natural history of distal radius fractures, studies show a decreased range of motion and grip strength one year after the fracture. Sixteen percent of people still report pain after 1 year. With this in mind, you can understand the importance of improving functional outcomes and decreasing pain in the first year, as shown in the intervention group that followed supervised physiotherapy.

Why did the between-group differences that favored the intervention group get smaller at the long-term follow-up of 2 years? Considering the primary outcome, people in the home exercise program group reported a score of 45.9 points at 6 weeks, while the intervention group reported a score of 27.3 simultaneously. This led to a large between-group difference that exceeded the MCID of 15 points. However, the baseline scores of both groups were not mentioned. We can’t therefore say if there was a huge difference between the groups at baseline and that this led to such a between-group difference. It could have also been possible that the home exercise group did not improve at all from baseline to 6 weeks, leading to the between-group difference. Therefore, some doubts remain. Since the baseline scores were not depicted in the paper, what scores the groups started need to be clarified. It could have been possible that the control group started the trial with much worse scores than the intervention group and this uncertainty should be taken into account.

Talk nerdy to me

The study was prospectively registered and the interventions were described according to the CONSORT statement. Two external assessors and the statistician were blinded to group allocation, the physiotherapist delivering the interventions and the participants were not. The interventions were standardized to ensure all patients in the same group received the same treatment.

This study underscores the necessity of supervised physiotherapy protocols in early rehabilitation stages for older adults with distal radius fractures. Importantly, the study’s findings apply to older adults undergoing non-surgical treatment with extra-articular distal radius fracture. The homogeneity of the sample, specifically the exclusion of surgically treated fractures, limits generalizability to all patients with a distal radius fracture.

The long-term follow-up revealed that while supervised physiotherapy offers significant early benefits, these advantages taper over time. The sustained improvement in grip strength suggests that specific functional gains might persist longer with supervised intervention.

This study provides valuable evidence for clinical decision-making, advocating for early supervised physiotherapy in distal radius fracture rehabilitation in older adults.

No patients dropped out from the study, which may indicate that the interventions were feasible for the enrolled patients.

Take home messages

Conservative distal radius fracture rehabilitation after cast immobilization favors supervised physiotherapy in the short- and long-term. At 2 years, the difference between the interventions washed out and only the grip strength was still significantly better in the intervention group. This study highlights the importance of supervised rehabilitation to achieve optimal short- and medium-term functional outcomes and pain relief in elderly patients with distal radius fractures. While home exercise programs can be beneficial, supervised sessions provide superior early-phase improvements. However, it was unclear what the baseline scores on the primary outcome were, and this limitation should be considered.

Reference

Gutiérrez-Espinoza, H., Gutiérrez-Monclus, R., Román-Veas, J., Valenzuela-Fuenzalida, J., Hagert, E., & Araya-Quintanilla, F. (2024). Effectiveness of supervised physiotherapy versus a home exercise program in patients with distal radius fracture: a randomized controlled trial with a 2-year follow-up. Physiotherapy. 2024